In nursing school we cover a broad range of material, but as we provide care we encounter patient scenarios in which we find ourselves thinking, “I wish we learned this in school.” Transgender health care is a common knowledge gap for health care providers, but it does not have to remain that way. In this article, we will cover the in’s and out’s of gender affirming care, the role of the bedside nurse in assessing risk, and communication tips to foster an inclusive patient-provider relationship.
You can watch the full recording with Sondra Smith, MSN, FNP-C below!
Sexual orientation: An inherent or immutable enduring emotional, romantic or sexual attraction to other people.
Gender identity: One's innermost concept of self as male, female, a blend of both or neither – how individuals perceive themselves and what they call themselves. One's gender identity can be the same or different from their sex assigned at birth.
Gender expression: External appearance of one's gender identity, usually expressed through behavior, clothing, haircut or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.
Gender identity is the innermost concept one holds of themself: as male, female, a blend, both, or neither. Identity is separate from orientation; i.e. being transgender doesn’t imply a sexual orientation.
Sexual orientation is one’s inherent emotional, romantic, or sexual attraction to other people. In this sense, gender is a social construct, as both gender identity and orientation are two different spectrums.
Here are some specific examples of gender as a social construct:
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), the term (gender dysphoria) - which replaces Gender Identity Disorder - "is intended to better characterize the experiences of affected children, adolescents, and adults."
As such, another way to look at gender identity is through the following terminology:
Androgynous - Identifying and/or presenting as neither distinguishably masculine nor feminine.
Asexual - The lack of a sexual attraction or desire for other people.
Cisgender - A person whose gender identity aligns with those typically associated with the sex assigned at birth.
Gender dysphoria - Clinically significant distress caused when a person's assigned birth gender is not the same as the one with which they identify.
Gender-expansive - Conveys a wider, more flexible range of gender identity and/or expression than typically associated with the binary gender system (i.e. color spectrum vs. Black and White)
Gender non-conforming - A broad term referring to people who do not behave in a way that conforms to the traditional expectations of their gender.
Genderqueer or non-binary - Genderqueer people typically reject notions of static categories of gender and embrace a fluidity of gender identity and often, though not always, sexual orientation. People who identify as "genderqueer" may see themselves as being both male and female, neither male nor female, or as falling completely outside of these categories.
Gender transition - The process of aligning internal knowledge of gender with outward appearance (hormone therapy, voice training, top/bottom surgery, etc.)
Pansexual - A person who is sexually/romantically attracted to people of all genders.
Queer - A term used to express any person with a sexual orientation or gender identity varying from traditional societal norms.
Transgender - Umbrella term for people whose gender identity and/or expression is different from cultural expectations based on sex assigned at birth. Doesn’t imply any specific sexual orientation.
Right now, there are three primary types of gender affirming care:
Hormone therapy typically entails the medical prescriptions of various hormones in order to alter bodily function and/or visual appearance.
For transgender women, estradiol plus an androgen blocker (spironolactone, and/or finasteride) are often prescribed. For transgender men, testosterone is the primary hormone used.
Lab monitoring typically follows a cadence of: before hormones, 3mo, 6mo, 9mo or 12mo, then Q6-12mo. The dose is based on desired effects, patient history, and lab monitoring
The primary goal of taking these substances is to affect skin, muscle, breast growth, body fat, hair growth, sex drive, sperm, and scalp hair (for transgender women); or alternatively, skin, muscle, voice pitch, body fat, hair growth, menses, clitoris, and scalp hair (for transgender men).
Surgical interventions are relatively self-explanatory.
Here is a list of common surgical interventions that is by no means exhaustive:
It’s important to keep in mind that these procedures are not always easy to find, paid for my insurance, or without their side effects.
There are also other interventions that are largely cosmetic but still function to help create a more complete and comfortable transformation.
So, while it’s great to have all of the above knowledge, how can we, as nurses, use it?
Ultimately, some biomarkers are difficult to assess fully due to the lack of research on transgender health care, but one universally prominent risk is thrombosis (or blood clots).
This is largely due to the varying levels of estrogen and testosterone in the body. With estrogen, the first first pass effect in the liver can affect clotting pathways; while, testosterone increases the red blood cell count and is why we monitor complete blood count.
Next, it’s important to be on the side of your patient, or an advocate. How?
Make sure you address your patient with the appropriate pronouns. What if you’re not sure how to do this?
Listen to your patient to pick up on who they most trust with medical information and procedures. It may be their biological family — a parent or a sibling, or it may be their chosen family — a significant other or friend. Involve these trusted members into their care.
Avoid assumptions surrounding their spouse or parents: i.e. instead of saying mom or dad, say parent; instead of saying husband or wife, say spouse or partner.
Some “good” red flags that help call out advocacy from nurse to patient could be a pride pin on your lapel or sharing where the gender neutral restrooms are located. These small gestures can help the patients feel welcomed and cared for.
What is HIV PrEP? HIV PrEP is HIV Pre-exposure prophylaxis. While gay and bisexual men account for approximately 70% of new HIV cases, one in seven people who are HIV+ are not aware of their HIV status.
So, who are the proper candidates?
While rates of exposure and respective risk different depending on type of activity or interaction, sexual promiscuity in the LGBTQ+ community is a myth—the overall LGBTQ+ population does not have vastly different sexual activity rates than heterosexual individuals.
Two possible drugs that can be taken proactively are Truvada and Descovy. They are once-daily medications that reduce risk of getting HIV by 99%. Typically, clinicians will check GFR & HIV status at: 3mo, 6mo, and then annually. Descovy, specifically, is approved for bisexual men, men who have sex with men, and transgender women.
Members of the LGBTQ+ community are at heightened risk for substance abuse, depression, and suicide.
LGBQ adults have 2x excess risk of suicide attempts compared to other adults, and transgender adults’ lifetime prevalence of suicide attempts is about 40%. The suicide risk is highest during teens-early 20s, and rates of completed suicides are hard to know because gender identity and sexual orientation are not reported in death records.
Factors affecting elevated suicide risk:
Factors that build resilience:
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